Inspection on 20/06/06 for Melrose Court

This inspection was carried out on 20th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Melrose Court 02/08/07

Melrose Court 26/10/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Melrose Court 74 Cambridge Road Southport Merseyside PR9 9RH Lead Inspector Mrs Elaine Stoddart Unannounced Inspection 20th June 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Melrose Court Address 74 Cambridge Road Southport Merseyside PR9 9RH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01704 226177 01704 226177 Melrose Court Rest Home Limited Mr Ian Burns Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Service users to include a maximum of 21 in the category of Old Persons, not falling within any other category. 26th October 2005 Date of last inspection Brief Description of the Service: Melrose Court is a residential care home, which is registered to provide personal care and support for up to 21 elderly residents. There were 18 residents accommodated at the time of the inspection. 18 single and 1 double rooms are provided. En suite facilities are provided in 4 single rooms and the double room. Communal areas consist of a 2 lounges, conservatory/dining room and smoking room. All are located on the lower ground floor. The residents use a large enclosed garden during the summer. All areas provide wheelchair access. There is parking at the front of the home. A call bell system is available throughout. Nursing care is provided when required by the district nursing service. The home is situated close to the seaside resort of Southport and its amenities can be accessed via the local transport. The registered manager is Mr Ian Burns and the home is owned by Melrose Court Rest Home LTD. The fee rate for accommodation is £355.50 a week. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day. It was an unannounced (site visit) and was conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. Requirements highlighted during the last inspection have been met been. A tour of the building and garden was conducted and a selection of care staff and home records were viewed. Case tracking was undertaken for 3 residents to assess the care provided at the home. This involved discussion with the manager, 5 staff members, 5 of the 18 residents and 1 relative to obtain their views obtained of the home. Satisfaction comment cards were also given to relatives to complete at their leisure. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents and relatives prior to the inspection. Comments included in the report are taken from the survey forms and also during the site visit. Positive comments were received regarding the home, the very caring nature of the staff and the service provided. What the service does well: The new owners have made progress in the last 10 months to improve the standard provided at the home. They are aware of the need for improvements, decoration and replacement of furnishings, however they have prioritised their maintenance plan by improving the exterior appearance of the building in replacing windows, painting the front outside and fire escape. Comments were received from the staff, relatives and residents interviewed regarding the improvements made. “I don’t have a draft through my windows anymore”(Resident). “The home is very homely”, (Relative). “This is the best home I have worked in.” “There is still a lot of work to do”(Staff). Relatives and visitors are made welcome and this was observed throughout the inspection, as visitors called to see their relatives, were made welcome by staff and some brought their young children with them. “I call in at all times of the day and everyone is so friendly. The staff are very caring,”(Relative). The home had a pleasant relaxed atmosphere and at the time of the inspection all areas were clean and hygienic. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 6 Staff recruitment and selection follows the correct procedures and all staff are employed following a POVA (Protection of Vulnerable Adults) check, 2 written references and an induction programme. Activities are provided and include Bingo, quiz, film shows, music and individual board games and word search. During the visit the residents were observed enjoying a bingo session with the staff on duty. Some staff provide one – one sessions with the residents playing board games and those spoken with said they enjoyed spending this individual time with staff. Positive comments were received from relatives spoken to and via surveys completed. “Christmas is lovely. There are BBQ’s and other activities which have been enjoyed by all and well organised”. The home provides a wholesome menu, which includes fresh vegetables and home cooked puddings, which the residents commented they enjoy very much. Comments from residents include- “I love the skin on the rice puddings”. ”The food is excellent. Better than you can get at home.” “The food is always freshly made and healthy” (Relative). Visitors are made welcome to the home to visit their relatives and this was observed during the visit as visitors popped in. One relative visits weekly and is always invited to stay for lunch. “They make me feel very welcome. The staff are lovely and the food is good”. Other positive comments received – “We are very happy with Melrose Court. The staff are so kind to our elderly mother and ourselves”. The staff on duty were found to be very polite, attentive and caring towards the residents. Staff spoken to commented “This is the best place I have worked in.” The residents spoken with were very complimentary regarding the staff employed. “They always listen”. “Staff are Angels”. “Staff are caring”. What has improved since the last inspection? The home has met the requirements and recommendations made at the last inspection. The home was found to be homely and clean a number of improvements have been made to improve the standard of accommodation and appearance. The manager/owner is aware of the need for improvements; decoration and refurbishment required and has made some progress in addressing these. The improvements made have mainly been to the exterior of the home to raise the standard and improve the appearance. These include new windows on top two Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 7 floors at the front, painting of the front exterior, new sophets, a new front door, rear garden paved and fire escape repainted. The maintenance plan is ongoing as there are further improvements planned. What they could do better: A tour of the premises was made and a number of areas in need of improvement and repairs noted. These were discussed with the manager during the inspection who agreed to take the appropriate action. These are noted within the requirements of this report. A copy of the home’s improvement plan is required to monitor progress. A recommendation was made to employ a maintenance person to deal with the day to day repairs and this will relieve the manager of these duties to enable more time to be applied to the day to day management of the home. The home should conduct regular environmental checks and record repairs in need of attention. Since the last inspection no staff training has taken place. The manager is to develop a training plan to ensure that all statutory training is kept up to date. This includes – health and safety, food hygiene, fire safety, infection control and manual handling. Further training is recommended in the administration of medication and adult protection. This should include the new procedures developed by Sefton Social and Liverpool Services ‘Safeguarding adults’. Staff are encouraged to obtain National Vocational Qualifications (NVQ), to ensure they are equipped with the skills to carry out their roles. This must continue to ensure that the standard of 50 of the care staff are trained in this area. Staff employed should be discouraged from working long shifts. This was discussed with the manager and viewing of duty rotas confirmed this. Window restrictors are in place, however the manager must ensure that these are always in use for the safety of the residents. . Staff interviewed requested regular staff meetings and supervision to ensure they are kept up to date. The manager must develop quality assurance surveys and regular residents meetings to assess progress since new ownership and obtain feedback from the residents, relatives and visitors to the home. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. (Standard 6 is not provided at the home). The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are provided with comprehensive information to enable them to decide whether to take up residency at the home. Pre admission assessments help ensure that the home can meet the needs of the residents and residents are provided with a contract stating terms and conditions of residency. EVIDENCE: The statement of purpose and service user guide is available to all residents, prospective residents and visitors to the home. Residents spoken to confirmed that they have copies of the service user guide in their rooms for reference. 3 care plans viewed identified all relevant aspects of health, social and personal care. Medical history, risk assessments and likes and dislikes are all recorded as part of the resident’s assessment process. Staff interviewed demonstrated a clear understanding of the care needs of the residents. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 11 Surveys completed by the residents confirmed that they have received contracts of terms and conditions and some were viewed in the care files. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The health, personal and social care needs of residents are understood and set out in an individual plan of care. Residents are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: Individual plans of care viewed demonstrated that care needs have been assessed and are reviewed regularly by the manager/supervisor. Staff interviewed showed a clear understanding of the needs of the residents and receive a handover at each shift change to keep them up to date with any change in circumstances. Where there is a need to involve other health care professionals this is conducted by the manager or senior on duty. Care files showed that access is available to dentist, GP, chiropodist and district nursing services when required. Feedback from surveys completed provided the following comments – Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 13 “If there has been a problem with health care it has always been seen to straight away.” (Relatives). “Medication issued regularly. If poorly the GP is called” (Relative). Medicines are administered according to the home’s policy and residents may self mediate if they so wish. Three MAR (medicine administration record) sheets were viewed as part of the case tracking process and these evidenced staff signatures following administration. A photograph of the resident is available for verification purposes. Blister packs are used for medicine administration and a list is kept of staff signatures for those responsible for this practice. Medicine awareness training is to be updated for all staff. Risk and manual handling assessments are in place and reveiwed regularly/or as and when there is a change of need. Care files easy to read and contained detailed information on care needs. Residents sign plan of care. Residents interviewed confirmed that they can see their own GP, dentist or optician and access community based services. Staff were observed as being polite and respectful towards the residents and providing assistance to residents with their meals in a sensitive fashion. Staff were helping residents with various aspects of personal care and this was carried out in an unhurried manner and with a gentle approach. It was evident from direct observation that the residents and staff get on very well together. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The daily life and routine in the home is flexible and residents are encouraged to make choices over their lives and day-to-day running of the home. Meals are wholesome and appealing and provided in comfort. EVIDENCE: The home offers a varied programme of social arrangements and on the day of the visit bingo was arranged for the residents. In house entertainment includes quizzes,films, music, word search, cards, dominoes and BBQs. Religious services are held at the home, this enables residents to continue to practice their faith. At present not many residents go out due to frail health however visitors are welcome at any time and invited to stay for lunch. Completed survey forms make reference to residents and relatives usually being pleased with the social arrangements in the home. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 15 “Christmas is lovely. There are BBQ’s and other activities which have been enjoyed by all and well organised” (Relative). “My mum could do with some stimulation on a personal basis. (Someone to talk to) as she doesn’t care for mixing in large numbers”(Relative). “I always take part in the activities” (Resident). Staff interviewed understood the need for residents to exercise choice and this was discussed in relation to clothing, food and personal care. Details of advocacy services are available and one resident is using this service. The home offers a varied menu and a copy of this was available in the dining area. A questionnaire seeking residents’ views regarding the food would be a good idea. Comments regarding the food include: “The meals are excellent”. (Resident). “I love the skin on the rice puddings”. (Resident). ”The food is excellent. Better than you can get at home.” (Resident). “The food is always freshly made and healthy” (Relative). The home has one cook and inspection of the kitchen confirmed that it was clean and there was a good supply of fresh, frozen and dry produce. Meals are generally served in the conservatory or in residents’ rooms if preferred. Dietary preferences are noted in the care plans and this information is made available to the cook. Fridge and freezer temperatures are recorded. Thoughout the inspection relatives and friends visited and were made welcome by the staff. A relative were spoken to said “The staff are all very nice and I am always made welcome and asked to stay for lunch”. The home has two lounges and a dining room/conservatory. These areas are used to provide activities, watch TV, sit and chat to relatives or listen to music. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. An abuse policy and procedures are in place for the home. Staff are not aware of the new ‘safeguarding adults policy’ and require training in Abuse. Recruitment and selection procedures are robust. All financial transactions made are recorded and receipts obtained. A complaints policy and procedure is in place. EVIDENCE: Policies and procedures are in place for finances, adult abuse and complaints. It is recommended that staff sign to acknowledge their understanding of all policies and procedures in place. Discussion with residents, a relative and surveys completed confirmed that they are aware of how to make a complaint.”But I have never had to make one” (Resident). One complaint has been recorded since the last inspection and was dealt with by the home and the resident was satisfied with the outcome. Discussion with the manager confirmed that further training is required in POVA (Protection of vulnerable dults) and the new Sefton and Liverpool procedures and will be included in their training plan which is identified as a requirement in this report. Staff spoken with confirmed their awareness of how to deal with any allegations. Some have had experience of allerting concerns in their previous jobs. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Surroundings are comfortable and homely. The new owners are addressing improvements, decoration and repairs required within an improvement plan. A record of response to day-to-day repairs is not in place. The home is clean and hygienic. EVIDENCE: Tour of the premises confirmed that the maintenance programme is continuing and progress has been made in - maintenance of fire escape, new windows on top two floors, sophets, front door and painting of front. The garden has been flagged. The maintenance programme is ongoing and the manager is to provide a maintenance plan and to develop a repairs reporting system including weekly room checks. It is recommended that the home employs a maintenace person to deal with day-to-day repairs and relieve the manager of Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 18 this responsibility and provide him with more time to manage the home. A number of repairs and improvements were identified (see requirements of this report). The manager must ensure that window restrictors in place are always used for the protection of the residents. (Information on standards regarding this was forwarded to home for reference). Residents rooms viewed contained personal possessions and were clean and comfortable. Positive comments were received regarding the environment from both residents and relatives. “I have the best room in the home. It is very comfortable”. “I have everything I need”. (Residents). “It is very homely” (Relative). “There is still a lot to do to improve the home” (Staff). The home was found to be clean and hygienic. Plenty of protective clothing is available and hand-washing facilities are in place. The laundry is located in the lower ground floor and quality equipment is available for use. Specialist equipment is available in the form of a bath hoist, raised toilet seats, wheelchairs, Zimmer frames and ramps for those residents with mobility needs. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The recruitment and selection procedures are robust. Staff must receive training to equip them with the skills to do their jobs to help safeguard and protect the people living in the home. EVIDENCE: On the day of the site visit 3 care staff, 1 senior, 1 domestic and the manager were on duty. The cook was on annual leave and 1 of the care staff was cooking the main meal, not providing personal care. The staffing rota for the month of May/june was viewed and this evidenced sufficient numbers of staff on duty. Discussion took place with the manager regarding sleep-in duties provided by the cook who then works a day shift. The manager is advised to change this to ensure that the employee does not work long shifts. Staff interviewed requested regular meetings to be held to discuss changes and developments in the home. 3 staff records were viewed and these evidenced completed job application forms and referees had been contacted for two references prior to commencing work at the home. CRBs (Criminal record bureau checks) are in place. Residents and relatives interviewed were complimentary regarding the standard of care they receive, comments included: Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 20 “Staff are very aproachable. I would live here if i had to go somewhere. The staff have helped my wife settle in very well (Relative). Staff are very kind.(Resident). They often do over and above what they need to do. (Resident). Staff are brill. (Resident). Through direct observation it was evident that staff provide a good standard of care however the home needs to update its training programme. A training plan for staff is required and discussion with the manager confirmed that this is a priority to ensure the staff have the knowledge to meet the needs of the residents. This must include – manual handling, fire safety, first aid, food hygiene and infection control. Further training is also recommended to be included in the training plan, for example abuse (as previously stated under the heading ‘Complaints and Protection’). Staff interviewed confirmed that they are undertaking NVQ qualifications and 6 have enrolled, 1 has almost completed the course and 3 have NVQ 3. Induction is in place for new staff. Supervision has been provided for some care staff and needs to be ongoing. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The manager is qualified and creates an open, inclusive management of the home. Residents finance records are recorded, securely stored. The lack of an up to date stafftraining programme can affect the health, safety and welfare of the residents. To ensure the home is run in the best interest of the service users the home must develop quality-monitoring systems. EVIDENCE: The manager has a qualification in NVQ Level 4. Staff interviewed commented on the day-to-day management and support provided. Comments received and viewing of records evidenced that the manager is very caring and Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 22 approachable, however since the last inspection has been concentrating on the refurbishment of the home and has had less contact with the day-to-day management. This has resulted in the lack of up to date staff training, supervision and regular staff and residents meetings. These issues were discussed with the manager during the visit and a number of requirements and recommendations made. It was recommended that he employs a maintenance person to deal with daily repairs to enable him to provide direction and supervision to the care staff. Residents and relatives spoken to confirmed their satfisfaction with the care and support provided and their needs are not being neglected. Staff are very supportive of the manager Ian is great and very laid back”. Pam (senior) is very good. Through observation it was evident that the management team and staff support the residents and have a good understanding of their individual needs. Completed survey forms referred to residents and their relatives being pleased with the home. The following comment were made, “The staff are very caring”. Residents manage their own finances were possible. Residents pay for chiropody and hairdressing visits.The home does not have a quality assurance system, which incorporates attaining feedback from residents and/or their representatives, for example, residents’ meetings or sending out regular satisfaction questionnaires regarding the service. This was discussed with the manager at the site visit. Policies and procedures should be reviewed annually and the manager is in the process of undertaking this. Policies and procedures should be circulated to staff to sign on acceptance and understanding. Staff take part in handovers at each shift change to discuss the care of the residents. A selection of safety contracts for equipment and services in the home were viewed. The gas, electric and fire prevention certificates were in date. There has been no recent service of the manual handling hoist and this was acted on immerdiatly by the manager. Fire alarms are tested weekly and the fire log book evidenced the most recent tests. Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable 3CHOICE OF HOME Standard No 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 3 2 Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement The registered person shall provide a planned maintenance programme outlining the continuing improvements to be made to the environment. A copy of this plan to be forwarded to CSCI. The registered person shall provide the following repairs and improvements identified at the site visit. Repair to carpet on first landing, replace carpet in room 3, paint ceiling on landing area, room 6 repair ceiling décor. The registered person shall ensure that a training plan is in place and all statutory training is brought up to date and includes – manual handling/fire safety/ food hygiene/infection control/first aid. The registered person shall develop quality-monitoring systems to obtain feedback on the service provided. I.e. surveys, regular staff and residents meetings. DS0000065047.V288842.R01.S.doc Timescale for action 31/07/06 2 OP19 23 30/09/06 3 OP30 18 30/09/06 4 OP33 35 30/09/06 Melrose Court Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP18 OP9 OP19 Good Practice Recommendations The registered person should provide abuse training and training on the new ‘Safeguarding Adults’ procedures. The registered person should provide training in medication administration. The registered person should provide regular environmental checks to identify repairs needed and record these in a repairs and maintenance book. The employment of a maintenance person is recommended to relieve the manager of this role. The registered person shall regularly check that the window restrictors in place are in use at all times. The registered person should avoid staff working long shifts. The registered person should ensure that the ongoing training programme for NVQ continues to achieve the 50 of qualified care staff. The registered manager should update policies and procedures, distribute to all staff and obtain signatures to verify their understanding. 4 5 6 7 OP19 OP27 OP28 OP37 Melrose Court DS0000065047.V288842.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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